Regional and temporal variability of GP consulta¬tions due to asthma in children aged 0-18 years in Silesian voivodeship - Epidemiological Review

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1 _{Department of Epidemiology, Medical Faculty in Katowice, Medical University of Silesia} in Katowice

_{'HSDUWPHQWRI%LRVWDWLVWLFV3XEOLF+HDOWK)DFXOW\LQ%\WRP0HGLFDO8QLYHUVLW\RI6LOHVLD} in Katowice

3 _{Department of Medical Research and Statistics, Department for Health Care System Supervision,} Silesian Voivodeship Office in Katowice

ABSTRACT

The aim of this study was toanalyzeWKHVSDWLDODQGWHPSRUDOYDULDELOLW\RIWKHUDWLRGHVFULELQJRXWSDWLHQWPHGLFDO YLVLWVGXHWRDVWKPDLQFKLOGUHQDJHG\HDUVOLYLQJin Silesian voivodeship.

0$7(5,$/$1'0(7+2'6. Descriptive study was conducted, in which secondary epidemiological data con-FHUQLQJQXPEHURIPHGLFDORXWSDWLHQWYLVLWVGXHWRDVWKPDRIFKLOGUHQLQWKHDJHRI\HDUVZHUHDQDO\]HG 7KHUHTXLUHGGDWDIURPWKHSHULRGZHUHUHSRUWHGRQWKH0=IRUP7RDVVHVVWKHWHPSRUDORUVSDWLDO YDULDELOLW\LQ6LOHVLDQYRLYRGHVKLSWKH$UF*,66RIWZDUHZDVXVHG

5(68/766LJQLILFDQWVSDWLDODQGWHPSRUDOYDULDELOLW\RIRXWSDWLHQWPHGLFDOYLVLWVGXHWRDVWKPDLQFKLOGUHQKDYH EHHQGLVFRYHUHG7KHV\VWHPDWLFDOLQFUHDVHRIRXWSDWLHQWYLVLWVUDWHZDVREVHUYHGUHVSHFWLYHO\DQG% compared to the starting year). The largest values of the ratio concern the central region of the Silesian voivode-ship. Most frequently outpatient medical visits due to asthma were related tochildren aged5-14years.

&21&/86,216Systematic anddetailed analysis of thedata collected in thehealth care systemcanreplace theroutine reporting andPD\EHXVHGto identifyneeds forSXEOLFKHDOWK

.H\ZRUGV childhood asthma, descriptive study, MZ-11 form INTRODUCTION

One of the routine document containing information RIKHDOWKSUREOHPVLVWKHDQQXDOUHSRUWRIDFWLYLWLHVDQG working in outpatient primary health care (MZ-11 form) (1). Necessary data are collected in regional offices and FDQEHXVHGIRUSXEOLFKHDOWKSXUSRVHVLQFOXGLQJREVHU-YDWLRQVRIWKHG\QDPLFVRIPHGLFDOEHQHILWV related to childhood asthma. The documentation allows to deter-PLQHWKHQXPEHURIFKLOGUHQDQGDGROHVFHQWVDJHG \HDUVZLWKWKHILUVWWLPHUHFRJQL]HGEURQFKLDODVWKPD (code J45 according to ICD-10) during a given period in those children who are patients of general practitioners *3%HFDXVHEURQFKLDODVWKPDLVRQHRIWKHFKURQLF GLVHDVHZLWKVWLOOJURZLQJIUHTXHQF\LWZDVFUXFLDO WR GHWHUPLQH WKH WHPSRUDO DQG VSDWLDO YDULDELOLW\ RI outpatient visits in particular aged groups of patients ZLWKUHFRJQL]HGEURQFKLDODVWKPD7KLVNQRZOHGJHPD\ appear very useful in the prophylactics planning actions,

especially in those regions, in which the frequency of asthma is the highest. Well known scientific arguments VXJJHVWWKDWFKLOGKRRGDVWKPDLVUHODWHGWRDPELHQWDLU SROOXWLRQ+HQFHLWLVZRUWKFRQVLGHULQJWRDVVHVV WKHUHODWLRQVKLSEHWZHHQUHJLVWHUHGRXWSDWLHQWYLVLWVGXH to childhood asthma with the quality of air and other determinants of health in particular regions.

The main goal of presented study was to assess the VSDWLDODQGWHPSRUDOYDULDELOLW\RIRXWSDWLHQWPHGLFDO YLVLWVGXHWRDVWKPDLQFKLOGUHQDQGDGROHVFHQWXQGHU years, who were the GP patients in Silesian voivodeship, LQ\HDUV

MATERIAL AND METHODS

The study was a descriptive epidemiological study. 'DWD RI RXWSDWLHQW PHGLFDO YLVLWV GXH WR EURQFKLDO asthma (code J45 according to ICD-10), including

first-0DáJRU]DWD.RZDOVND(ZD1LHZLDGRPVNDHWDO

 No 3

WLPHYLVLWVLQFKLOGUHQDQGDGROHVFHQWXQGHU\HDUV ZDVREWDLQHGIURPWKH'HSDUWPHQWRI0HGLFDO5HVHDUFK and Statistics, Silesian Voivodeship Office in Katowice. Annual report (MZ-11 form) of the activities and work-ing in outpatient primary health care (GP) concern the SHULRGDQGGHVFULEHWKHQXPEHURIFKLOGUHQ DJHG\HDUVFRQVXOWHGE\*3LQ6LOHVLDQYRLYRGH-ship, and separately for all counties in study region.

7KHVXEMHFWVZHUHFKLOGUHQZLWKUHFRJQL]HGDVWKPD LQILYHDJHFDWHJRULHVDQG \HDUV2EWDLQHGGDWDLQFOXGHGDOVRWKHWRWDOQXPEHU of children in selected aged groups enrolled in PHC (primary health care) in particular counties of Silesian voivodeship. The study includedtwo levels of administra-tive division inSilesian voivodeship: regional level (NTS 3) with theeightVXEUHJLRQVVXFKDV&]ĊVWRFKRZD%\WRP

6RVQRZLHF*OLZLFH.DWRZLFH5\EQLN7\FK\%LHOVNR %LDáDDQGORFDOOHYHO176ZLWKFRXQWLHVDQG cities with county status. NTS (Nomenclatureof Territorial Unitsfor Statistics) is an orderedlist of the namesof territorial unitsand their associatedV\PEROVusedinthe collectionof VWDWLVWLFVE\the Central Statistical Office

5DWHVGHVFULE-LQJWKHQXPEHURIFKLOGUHQZLWKRXWSDWLHQWPHGLFDOYLVLWV due to asthma (including first-time visits) in particular years and particular counties were calculated. The final rates are presented as the value calculated per 10 000 children. The temporal trends of rates in the study period \HDUVZHUHDQDO\]HG)LQDOO\LWVWHUULWRULDO YDULDELOLW\ LQ FRXQWLHV RI 6LOHVLDQ YRLYRGHVKLS ZHUH presented as a value of rates averaged for studied period \HDUV%RWKWHPSRUDODQGWHUULWRULDOYDULDELOLW\LQ SRYLDWVRI6LOHVLDQYRLYRGHVKLSZHUHLOOXVWUDWHGE\WKH $UF*,6VRIWZDUH)LJDQG,Qthe statistical analysismethodsDYDLODEOHin the softwareStatistica9.0.PL and procedures included in 06([FHO were used.

RESULTS

7KHQXPEHURIFKLOGUHQZLWKRXWSDWLHQWPHGLFDOYLVLWV GXHWREURQFKLDODVWKPD-SDWLHQWVRI*3VORFDWHGLQ 6LOHVLDQYRLYRGHVKLSKDVVWHDGLO\LQFUHDVHGWKHREVHUYHG JURZWKZDVLQWKHVWXG\SHULRG7DE, It was mostly related to an increase of the first-time visits.

,Qmore than inFKLOGUHQwere registered,which meansthat theREVHUYHGgrowthstands at compared to the first year of study period.7KHUDWLRGHVFULELQJWKH

QXPEHURIFKLOGUHQDQGDGROHVFHQWDJHG\HDUVZLWK UHFRJQL]HGEURQFKLDODVWKPD-DQGVLPXOWDQHRXVO\ WUHDWHGE\D*3LQLQ6LOHVLDQYRLYRGHVKLS increased, also for the first-time-visits.

7DEOH, 1XPEHUDQGUDWHVQRIRXWSDWLHQWPHGLFDO YLVLWVGXHWRDVWKPD-LQFKLOGUHQDJHG years, GP patients in Silesian voivodeship.

Year 1XPEHU of medical visits due to asthma N 1XPEHU RI¿UVWWLPH medical visits due to asthma N (%) Rate of medical visits due to asthma (n/10 000) Rate of ¿UVWWLPH medical visits due to asthma (n/10 000)   _(14.0%)  35.0   _(13.0%)  35.0   _(14.4%)3530     _   7KHQXPEHURIFKLOGUHQZLWKGLDJQRVHGDVWKPD patients of primary health care, increase in all aged groups, however the largest percentage of sick children ZDVREVHUYHGLQWKHDJHJURXSRI\HDUVDQGWKH VPDOOHVW±LQFKLOGUHQDJHG\HDUV7DE,,

7KLVWUHQGZDVDOVRREVHUYHGLQWKHWHPSRUDODQG spatial terms, (Figure 1) except of the decreasing the QXPEHURIFKLOGUHQZLWKRXWSDWLHQWYLVLWVLQSRYLDWRI 7\FK\LQ6LPLODUO\WKHV\VWHPDWLFLQFUHDVHRI WKHQXPEHURIFKLOGUHQZLWKILUVWWLPHRXWSDWLHQWYLVLWV ZDVREVHUYHGLQPRVWFRXQWLHVLQ6LOHVLDQYRLYRGHVKLS H[FOXGLQJ&]ĊVWRFKRZDDQG*OLZLFHSRYLDWV)LJXUH

There was an increase of outpatient medical visits rates in almost all counties of Silesian voivodeship 7DEOH,,,ZLWKWKHODUJHVWDYHUDJHGUDWLRPHDQYDOXH IRUWKHVWXG\SHULRGLQ7\FK\VXEUHJLRQ DQGZLWKWKHVPDOOHVW±LQ5\EQLNVXEUHJLRQ

Figure 3 illustrates the values of the averaged ratio GHVFULELQJWKHQXPEHURIFKLOGUHQZLWKDVWKPDLQ3+& GXULQJWKHVWXG\SHULRG\HDUV,WVKRZVWKDW

7DEOH,, 1XPEHURIRXWSDWLHQWPHGLFDOYLVLWVGXHWRDVWKPD-LQFKLOGUHQDJHG\HDUVDQGWKHSHUFHQWDJHRIFKLOGUHQ treated in the particular age groups, Silesian voivodeship.

Year 1XPEHURIFKLOGUHQ N 1XPEHUDQGSHUFHQWDJHRIRXWSDWLHQWPHGLFDOYLVLWVGXHWRDVWKPDLQSDUWLFXODUDJHGJURXSVRIFKLOGUHQ (N (%)  years 3-4 years 5-9

years 10-14 years \HDUV

     6539 (30.3%) 

      4313 (19.5%)

      

5\EQLNSRYLDWZDVWKHUHJLRQZLWKWKHVPDOOHVWUDWLR FKLOGUHQXQGHU\HDUVDQG-DZRU]QR SRYLDW KDG WKH ODUJHVW YDOXH   FKLOGUHQ XQGHU\HDUV6LPLODUO\WKHORZHVWDYHUDJHGUDWLR GHVFULELQJWKHQXPEHURIFKLOGUHQZLWKWKHILUVWWLPH UHFRJQL]HG DVWKPD ZDV REVHUYHG LQ 5\EQLN SRYLDW RIFKLOGUHQXQGHU\HDUVDQGWKHODUJ

7DEOH,,,7KHUDWLRGHVFULELQJWRWDODQGILUVWWLPHRXWSDWLHQWPHGLFDOYLVLWVGXHWRDVWKPDLQFKLOGUHQDJHG\HDUVLQ particular counties of the Silesian voivodeship (n/10 000).

Counties Outpatient medical visits per 10000 children Ratio averaged for the

SHULRG

Year    

ELHOVNL total _{¿UVWWLPHYLVLWV} _ _ _43.5 345.0_ _ E\WRPVNL total _{¿UVWWLPHYLVLWV} _ 306.4_ 306.4_59.3 353.4_ _ F]ĊVWRFKRZVNL total _{¿UVWWLPHYLVLWV} _  40.3   331.436.9   gliwicki total ¿UVWWLPHYLVLWV     39.0 katowicki total _{¿UVWWLPHYLVLWV} 

40.1



   44.5 U\EQLFNL total _{¿UVWWLPHYLVLWV} _ _ _ 

34.4

 30.1 sosnowiecki total _{¿UVWWLPHYLVLWV} 

39.1 310.4  45.9   43.3 tyski total ¿UVWWLPHYLVLWV     34.9

Fig. 3. Averaged ratio of the outpatient medical visits GXHWRDVWKPD-LQFKLOGUHQDJHG\HDUV QVWXG\SHULRG6LOHVLDQYR ivodeship.

)LJ 1XPEHURIRXWSDWLHQWPHGLFDOYLVLWVGXHWRDVWKPD - LQ FKLOGUHQDJHG  \HDUV LQ SDUWLFXODU counties of Silesian voivodeship, study period 

)LJ 1XPEHURIILUVWRXWSDWLHQWPHGLFDOYLVLWVGXHWR DVWKPD-LQFKLOGUHQDJHG\HDUVLQSDUWL cular counties of Silesian voivodeship, study period 

0DáJRU]DWD.RZDOVND(ZD1LHZLDGRPVNDHWDO

500 No 3

HVWZDVQRWHGLQĝZLĊWRFKáRZLFHSRYLDW FKLOGUHQLQWKHDJHRI)LJXUH

Fig. 4. Averaged ratio of first outpatient medical visits GXHWRDVWKPD-LQFKLOGUHQDJHG\HDUV QVWXG\SHULRG6LOHVLDQYR ivodeship. DISCUSSION 7KHREWDLQHGUHVXOWVVKRZWKHVLJQLILFDQWWHPSRUDO DQGVSDWLDOYDULDELOLW\RIWKHUDWLRGHVFULELQJWKHQXPEHU of outpatient medical visits in PHC among children with recognized asthma. The systematic increase of ratio de-VFULELQJWKHQXPEHURIFKLOGUHQZLWKUHFRJQL]HGDVWKPD LQFOXGLQJILUVWWLPHUHFRJQL]HGGLVHDVHZDVREVHUYHGLQ WKHPRVWRIVXEUHJLRQVLQ6LOHVLDQYRLYRGHVKLSH[FHSW WKH&]ĊVWRFKRZDVXEUHJLRQ7KHODUJHVWSHUFHQWDJHRI the outpatient medical visits in PHC concern the age JURXSRI\HDUVDQGWKHORZHVWZDVREVHUYHGLQ WKH\RXQJHVWFKLOGUHQLH\HDUV7KLVREVHUYDWLRQLV FRKHUHQWZLWKGDWDSUHVHQWHGE\,6$$&VWXG\,QWHUQD tional Study of Asthma and Allergies in Childhood), in which the estimated frequency of asthma symptoms in Polish children was the highest in the aged group 13-14 \HDUVDERXWFKLOGUHQLQ3R]QDĔ,WLVZRUWK QRWLFLQJWKDWWKHQXPEHURIWKH\RXQJHVWFKLOGUHQLH \HDUVZLWKGLDJQRVHGDVWKPDDQGFRQVXOWHGE\*3 LQ3+&LQ6LOHVLDQYRLYRGHVKLSZDVGRXEOHGLQWKHVWXG\ SHULRGZKLOHWKHQXPEHURIWKHROGHVWFKLOGUHQ \HDUVZDVVWDEOH6\VWHPDWLFVWXGLHVFRQGXFWHGE\WKH Department of Epidemiology, Medical University of Sile-sia in Katowice, suggest the significant under-diagnosis RIDVWKPDLQVFKRRODJHFKLOGUHQZKLFKVWDQGDERXW (5,6). The results of the current study (BUPAS) conducted E\WKH'HSDUWPHQWDPRQJFKLOGUHQDJHG\HDUV suggest, that the frequency of ever diagnosed asthma or its symptoms were larger in cities than in rural areas LQ6LOHVLDQYRLYRGHVKLS$QLQFUHDVLQJQXPEHURI children with asthma, including the youngest children, FRXOGEHDQHIIHFWRIJURZLQJSDUHQWDODZDUHQHVVDVZHOO DVEHWWHUGLDJQRVLVRIFKLOGKRRGDVWKPD,WLVFRQVLGHUHG WKDWXQGHUGLDJQRVLVRIDVWKPDE\WKH*3LQFKLOGUHQDJHG \HDUVGXULQJWKHILUVWYLVLWLQ3+&VWDQGVDW and is systematically decreasing during following visits ([LVWLQJGDWDVXJJHVWWKDWRSWLPDOFRQWURORIWKH GLVHDVHLQFKLOGUHQLVSRVVLEOHRQO\LQFDVHRIFORVHFR RSHUDWLRQEHWZHHQFKLOGUHQWKHLUSDUHQWVDQGWKHPHGLFDO VWDIIHVSHFLDOO\*33UHVXPDEO\WKHEHWWHUSULPDU\ health care for children with asthma in partnership with WKHLUSDUHQWVLVWKHOLNHO\FDXVHRIGHFOLQHLQWKHQXPEHU of asthmatic patients hospitalized due to asthma in clinical hospitals in Japan (10) and the UK (11). Results of the other study confirm that the proper care of specialized QXUVHDQGRU*3LQFKLOGUHQDJHG\HDUVZLWKVWDEOH DVWKPDLVDFWXDOO\VXIILFLHQWIRUWKHWUHDWPHQW

$QLPSRUWDQWREVHUYDWLRQLVWKHORFDWLRQRIWKHKLJK est values RIWKHWZRLQGLFDWRUVGHVFULELQJDOOYLVLWVGXH to childhood asthma and first-time visits) in the central part of Silesian voivodeship. Worth noting is that the ODUJHVWDYHUDJHGYDOXHVRIWRWDOUDWHVZHUHREVHUYHGLQ Jaworzno county, and the largest averaged value of first-WLPHPHGLFDOYLVLWVZHUHQRWHGLQĝZLĊWRFKáRZLFHDQG -DZRU]QRFRXQWLHV7KHORZHVWYDOXHVRIERWKUDWHVZHUH REVHUYHGLQ5\EQLNFRXQW\,WLVQRWH[FOXGHGWKHLPSDFW of environmental exposure associated with the quality of DPELHQWDLUWKHDYDLODEOHSXEOLVKHGGDWDVXJJHVWWKDW the higher incidence of acute respiratory diseases (and KHQFHKLJKHUQXPEHURIRXWSDWLHQWPHGLFDOYLVLWVUHIHUV days with poorer air quality (13). Recent studies indicate VLJQLILFDQWUHODWLRQVKLSEHWZHHQLQFLGHQFHRIFKLOGKRRG asthma and location of residence, disease occurs more frequently in children living near roads with heavy traffic (14,15,16). However, it is difficult to relate this knowl-HGJHWRREWDLQHGUHVXOWVVKRZLQJWKHWHUULWRULDOYDULDELO LW\RIUDWHVGHVFULELQJQXPEHURIFKLOGUHQZLWKDVWKPD GLDJQRVHGE\*37KHPDLQOLPLWDWLRQRIWKHLQWHUSUHWD tion is secondary character of data used in the analysis. 5HFHQWGDWDRIDYHUDJHOHYHOVRIDLUSROOXWLRQREWDLQHG from monitoring stations in Silesian voivodeship show a similar air quality in regions with the highest and lowest YDOXHVRIRXWSDWLHQWPHGLFDOYLVLWV3HUKDSVKHUH reveals the impact of industrialization and the existing roads with heavy traffic in the various counties. However

GHILQLWLYHFRQFOXVLRQVFDQQRWEHGUDZQZLWKRXWIXUWKHU study in the field of environmental epidemiology, with the use of direct assessment of exposure to environmental pollution, relevant to the pathogenesis of asthma.

Moreover, socio-economic conditions of child’s families, including housing and lifestyle of parents (e.g. WREDFFRVPRNLQJRUDYDLODELOLW\RIPHGLFDOVHUYLFHV DOVRKDYHDQLPSDFWRQWKHQXPEHURIRXWSDWLHQWPHGLFDO visits. Analogously, the clear requesting require some spe-cific data. The applied model of study allowed to identify WKHYDULDELOLW\RI*3YLVLWVGXHWRFKLOGKRRGDVWKPDLQ particular counties of Silesian voivodeship. Such a popu-lation diagnosis meaningfully supports activities in the ILHOGRISXEOLFKHDOWKDQGLWVKRXOGEHXVHGLQWKHSODQQLQJ RIKHDOWKEHQHILWVDVVRFLDWHGZLWKWKHDQDO\]HGGLVHDVH 0RUHRYHUWKHREWDLQHGSHUVSHFWLYHSURYHVWKDWLQWHQVLYH study in the field of environmental epidemiology, aiming to explain the reasons of territorial differentiation of the prevalence of childhood asthma.

CONLUSIONS 7KHV\VWHPDWLFLQFUHDVHDQGVSDWLDOYDULDELOLW\RI UDWHVGHVFULELQJWKHQXPEHURIFKLOGUHQDQGDGROHVFHQWV ZLWKGLDJQRVHGDVWKPDFRQVXOWHGE\*3ZHUHREVHUYHG LQ6LOHVLDQYRLYRGHVKLS&RQFOXGLQJWKHREWDLQHGUH-VXOWVWKHLQWHQWLRQDODQDO\VLVRIURXWLQHGDWDVKRXOGEH XVHGLQUHODWLRQWRQHHGVRISXEOLFKHDOWK REFERENCES

1. Annual report on the activities and employment in the SULPDU\DPEXODWRU\KHDOWKFDUH0=IRUPZZZ FVLR]JRYSOVUFILOHVP]0=BSGI DFFHVV >,Q3ROLVK@

 &(+$37KHSODQIRUWKHHQYLURQPHQWDQGWKHKHDOWK of children. Diseases of the respiratory system and the TXDOLW\RIWKHDLUZZZFHKDSSO'LDJQR]DKWPO DFFHVV>,Q3ROLVK@

3. The Nomenclature of Territorial Units for Statistical Pur-SRVHV176&HQWUDO6WDWLVWLFDO2IILFHZZZVWDWJRYSO JXVBB3/.B+70/KWPDFFHVV >,Q3ROLVK@  7KH*OREDO$VWKPD5HSRUW,6$$&,QWHUQDWLRQDO 6WXG\RI$VWKPDDQG$OOHUJLHVLQ&KLOGKRRG'RVWĊS ZZZWKHXQLRQRUJLPDJHVVWRULHVSUHVVUHOHDVH *ORE-DOBDVWKPDUHSRUWSGIF\WRZDQ\ 5. %URĪHN*=HMGD-(:\S\FK$)DUQLN0:KHUHDUH WKH\"8QGHUGLDJQRVLVRIFKLOGKRRGDVWKPDLQ3RODQG $OOHUJ\9RO6XSSOWK($$&,&RQJUHVV of the European Academy of Allergology and Clinical ,PPXQRORJ\%DUFHORQD>6SDLQ@$EVWU S>@

 %URĪHN*0=HMGD-(.RZDOVND0*ĊEXĞ0,JLHOVNL M. Opposite trends of allergic disorders and respiratory

V\PSWRPVIRUFKLOGUHQRYHUDSHULRGRIODUJHVFDOHDPEL-HQWDLUSROOXWLRQGHFOLQH3-2(6  6KSDNRX$%URĪHN*6WU\]KDN$1HYLDUWRYLFK7=HMGD

-$OOHUJLFGLVHDVHVDQGUHVSLUDWRU\V\PSWRPVLQXUEDQ and rural children in Grodno Region (Belarus). Pediatr $OOHUJ\,PPXQRO±

 *XDUQDFFLD6/RPEDUGL$*DIIXULQL$&KLDULQL0 Domenighini S, D’Agata E, Schumacher R.F, Spiazzi R, Notarangelo L.D. Application and implementation of WKH*,1$DVWKPDJXLGHOLQHVE\VSHFLDOLVWDQGSULPDU\ FDUHSK\VLFLDQVDORQJLWXGLQDOIROORZXSVWXG\RQ FKLOGUHQ3ULP&DUH5HVSLU- 9. Moth G, Schiotz P.O, Vedsted P. A Danish

population- EDVHGNRKRUWVWXG\RIQHZO\GLDJQRVHGDVWKPDWLFFKLO-dren’s care pathway – adherence to guidelines. BMC +HDOWK6HUYL5HV

 0DHGD7+RULED0)XUXL+7UHQGVLQDVWKPDPDQDJH-ment over a ten-year period in Gifu Prefecture. Arerugi 

11. Butland B.K, Strachan D.P, Crawley-Boevey E.E, An-derson H.R. Childhood asthma in south London: trends LQSUHYDOHQFHDQGXVHRIPHGLFDOVHUYLFHV 7KRUD[

 .XHWKH09DHVVHQ9HUEHUQH$0XOGHU3%LQGHOV3YDQ $DOGHUHQ:3DHGLDWULFDVWKPDRXWSDWLHQWFDUHE\DVWKPD nurce, paediatrician or general practitioner: randomised controlled trial with two-year follow-up. Prim Care 5HVSLU-

 %LHVLDGD0=HMGD-(6NLED0$LUSROOXWLRQDQGDFXWH respiratory diseases for children: regression analysis of PRUELGLW\GDWD3RO-2FFXS0HG(QYLURQ+HDOWK 

 6NU]\SHN0:\VWĊSRZDQLHFKRUyELREMDZyZ]HVWURQ\ XNáDGXRGGHFKRZHJRXG]LHFLDZLHONRĞüSRWHQFMDOQHJR QDUDĪHQLDQDNRPXQLNDF\MQH]DQLHF]\V]F]HQLDSRZLHWU]D atmosferycznego. Rozprawa doktorska SUM w Katow-LFDFK3URPRWRUSURI-(=HMGD>,Q3ROLVK@  .DV]QLD.RFRW-.RZDOVND0*yUQ\5/1LHVOHU$

:\S\FKĝOXVDUVND$ (QYLURQPHQWDO ULVN IDFWRUV IRU respiratory symptoms and childhood asthma. Ann Agric (QYLURQ0HG±

16. Gruzieva O, Bergstrom A, Hulchiy O, Kull I, Lind T, Melen E, Moskalenko V, Pershagen G, Bellander T. Ex-posure to air pollution from traffic and childhood asthma XQWLO\HDUVRIDJH(SLGHPLRORJ\  ĝOąVNLPRQLWRULQJSRZLHWU]D3DĔVWZRZ\,QVSHNWRUDW2FK-URQ\ĝURGRZLVNDZ.DWRZLFDFKZZZVWDFMHNDWRZLFH SLRVJRYSOPRQLWRULQJDFFHVV>,Q3ROLVK@ 5HFHLYHG $FFHSWHGIRUSXEOLFDWLRQ $GGUHVVIRUFRUUHVSRQGHQFH 'UKDE0DáJRU]DWD.RZDOVND Department of Epidemiology, Medical University of Silesia .DWRZLFH0HG\NyZVWU e-mail: mkowalska@sum.edu.pl WHO